PSMA-expressing metastases: melanoma or prostate carcinoma?

Is it stage III melanoma and stage IV prostate cancer or stage IV melanoma bone and lymph node metastases? That's the question doctors recently faced when an elderly man with PSMA-expressing metastases presented to a German clinic. He was previously treated for prostate cancer and melanoma.

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Positron emission tomography (PET) with 68Ga prostate-specific membrane antigen (PSMA) and computed tomography (CT) can detect metastases in prostate cancer. However, PSMA expression can sometimes occur in other tumors as well, making it difficult to establish a clear diagnosis.

In 2019, a 70-year-old patient was diagnosed with melanoma of the left forearm (Breslow depth 1.4 mm, no lesion [pT2a]) after complete excision, local re-excision with a safety margin of 10 mm was performed. At the patient's request, a sentinel biopsy was not performed at this time.
He was diagnosed with prostate cancer 13 years ago and treated with radical prostatectomy and salvage radiotherapy for recurrence 5 years after diagnosis.
During a test in 2022, an elevated serum level of prostate-specific antigen (PSA) was detected (0.58ng/ml) and a PSMA-PET/CT was ordered to detect possible recurrence. It demonstrated two lesions: a PSMA-positive, significantly enlarged left axillary lymph node and a PSMA-positive osteolytic lesion in the L5 lumbar vertebral body.

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